Department of Human Services Approved PDL for IOWA Medicaid Program ALPHA DRUG LIST trusted, reliable, innovative Highlighted drugs denote new changes to the Effective Date 01/01/2019 PDL since previous update Column Header Explanations: P, N, R or NR: B, G or O: P = Preferred B = Brand N = Non-Preferred G = Generic R = Recommended O = OTC NR = Non-Recommended B Drug Name Drug Category P, N, Comment or R or G NR A G Abacavir Sulfate Antiretrovirals - Rti - Nucleoside/Nucleotide Analogues P G Abacavir Sulfate-Lamivudine-Zidovudine Antiretrovirals - Combinations NR G Abacavir-lamivudine Antiretrovirals - Combinations P B ABILIFY Antipsychotics - Atypicals N PA Required B ABILIFY DISCMELT Antipsychotics - Atypicals NP PA Required B ABILIFY MAINTENA Antipsychotics - Atypicals P B ABSORICA Acne Products: Isotretinoin N PA Required B ABSTRAL Narcotics - Misc. NP PA Required G Acamprosate Calcium Alcohol Deterrents P B ACANYA Topical - Acne Preparations P PA Required G Acarbose Diabetic - Alphaglucosidase P B ACCOLATE Antiasthmatic - Leukotriene Receptor Antagonists NP B ACCUPRIL ACE Inhibitors NP B ACCURETIC ACE and Thiazide Combo's NP G Acebutolol HCl Beta Blockers - Cardio Selective P O Acetaminophen Analgesics - Misc. P G Acetaminophen w/ Codeine Narcotics - Misc. P PA Required < 18 years of age G Acetazolamide Diuretics P G Acetic Acid Urological - Misc. P G Acetic Acid (Otic) Ear P G Acetic Acid-Aluminum Acetate Ear NP G Acetylcysteine Antiasthmatic - Mucolytics P 12/17/2018 9:18:23 AM Page 1 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B ACIPHEX Gi - Proton Pump Inhibitor NP PA Required G Acitretin Anti-Psoriatics - Non-Biologicals NP B ACTEMRA Anti-Inflammatories, Non-Nsaid NP PA Required B ACTIGALL Gi - Misc. NP B ACTIMMUNE Interferon Gamma NP B ACTIQ Narcotics - Misc. NP PA Required B ACTIVASE Tissue Plasminogen Activator P B ACTIVELLA Estrogen Combos NP B ACTONEL Osteoporosis NP B ACTOPLUS MET Diabetic - Thiazol / Biguanide Combo NP B ACTOPLUS MET XR Diabetic - Thiazol / Biguanide Combo NP B ACTOS Diabetic - Thiazol NP B ACULAR Op. Nsaid'S NP B ACUVAIL Op. Nsaid'S NP G Acyclovir Herpes Agents P G Acyclovir Sodium Herpes Agents P G Acyclovir SUSP Herpes Agents P G Acyclovir Topical Topical - Antivirals NP B Aczone Topical - Acne Preparations N PA Required B ADALAT CC Calcium Channel Blockers--Nifedipines NP G Adapalene cream Topical - Acne Preparations NP PA Required G Adapalene gel 0.1% Topical - Acne Preparations P PA Required G Adapalene gel 0.3% Topical - Acne Preparations P PA Required G Adapalene lotion Topical - Acne Preparations NP PA Required G adapalene solution Topical - Acne Preparations N PA Required G Adapalene/benzoyl peroxide Topical - Acne Preparations N PA Required B ADCIRCA Pulmonary Anti-Hypertensives NP Grandfather Existing Users B ADDERALL Stimulants - Amphetamines - Short Acting NP PA Required B ADDERALL XR Stimulants - Amphetamines - Long Acting NP PA Required G Adefovir Dipivoxil Hepatitis B Only NP B ADEMPAS Pulmonary Anti-Hypertensives NP PA Required B Adlyxin Diabetic - Non-Insulin Injectables N PA Required B Admelog Diabetic - Insulin N B Admelog Solostar Diabetic - Insulin Penfills N PA Required 12/17/2018 9:18:23 AM Page 2 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B ADOXA Tetracyclines NP PA Required B ADRENACLICK Anaphylaxis Therapy NP B ADRENALIN Anaphylaxis Therapy NP B ADVAIR Antiasthmatic - Adrenergic Combos P B ADVAIR HFA Antiasthmatic - Adrenergic Combos P B ADVATE Antihemophilia Factor VIII Agents P B ADVICOR Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP B Adynovate Antihemophilia Factor VIII Agents N B Adzenys er oral suspension Stimulants N PA Required B Adzenys XR ODT STIMULANTS NP PA Required B AEROSPAN Antiasthmatic - Steroid Inhalants N B AFINITOR Antineoplastics - Protein-Tyrosine Kinase Inhibitors R PA Required B Afluria 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B Afluria PF 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B Afluria Quad 2018-19 Influenza Agents P Those 0-18 should be referred to the Vaccines for Children Program. B AFREZZA Diabetic - Insulin NP B Afstyla Antihemophilia Factor VIII Agents N B AGGRENOX Platelet Aggr. Inhibitors / Combo's - Misc. P B AGRYLIN Platelet Aggr. Inhibitors / Combo's - Misc. NP B A-HYDROCORT Glucocorticoids - Mineralocorticoids P B Aimovig CGRP Inhibitors N PA Required B Airduo respiclick Antiasthmatic - Adrenergic Combos N B Ajovy CGRP Inhibitors N PA Required B AKNE-MYCIN Topical - Acne Preparations NP PA Required B AKYNZEO Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B ALBENZA Anthelmintics P G Albumin, Human Electrolytes/ Nutritionals NP G Albuterol Sulfate NEBU 0.63MG/3 Antiasthmatic - Beta - Adrenergics P Preferred < 2 years of age G Albuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML) Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML) Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Soln Nebu 1.25 MG/3ML (Base Equiv) Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Syrup 2 MG/5ML Antiasthmatic - Beta - Adrenergics P 12/17/2018 9:18:23 AM Page 3 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A G Albuterol Sulfate Tab 2 MG Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Tab 4 MG Antiasthmatic - Beta - Adrenergics NP G Albuterol Sulfate Tab SR 12HR 4 MG Antiasthmatic - Beta - Adrenergics P G Albuterol Sulfate Tab SR 12HR 8 MG Antiasthmatic - Beta - Adrenergics P B ALCAINE Op. Misc NP G Alclometasone Dipropionate Topical - Corticosteroids - Low Potency N PA Required B ALDACTAZIDE TAB 25/25 Diuretics NP B ALDACTAZIDE TABS 50/50 Diuretics P B ALDACTONE Diuretics NP B ALDARA Topical - Genital Warts NP Payable for members who are 12 years of age and older. Quantity limitations of 12 packets/4 weeks (28 days) or a total of 48 packets/16 weeks (112 days). B ALDURAZYME Mucopolysaccharidosis P B Alecensa Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required G Alendronate Sodium Osteoporosis P G Alendronate Sodium SOLN Osteoporosis NP G Alfuzosin HCl BPH P B ALINIA Antiprotozoal Agents P B ALKERAN Antineoplastics - Nitrogen Mustards R G Allopurinol Gout P G Almotriptan Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B ALOCRIL Op. Antiallergics - Mast Cell Stabilizers NP G Alogliptin Diabetic - Other N PA Required G Alogliptin-metformin Diabetic - Other N PA Required G Alogliptin-pioglitazone Diabetic - Other N PA Required B ALOMIDE Op. Antiallergics - Mast Cell Stabilizers NP B ALORA Estrogens - Patches P G Alosetron Gi - Irritable Bowel Syndrome Agents NP B ALOXI Antiemetic - 5-HT3 Receptor Antagonists/ Substance P Neurokinin NP PA Required B ALPHAGAN P SOL 0.1% Op. Selective Alpha Adrenergic Agonists P B ALPHAGAN P SOLN 0.15% Op. Selective Alpha Adrenergic Agonists P B ALPHANATE Antihemophilia Factor von Willebrand Factor Agents P B ALPHANINE SD Antihemophilia Factor IX Agents P G Alprazolam Anxiolytics - Benzodiazepines P 12/17/2018 9:18:23 AM Page 4 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B ALPRAZOLAM INTENSOL Anxiolytics - Benzodiazepines P G Alprazolam Tab SR 24HR 0.5 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 1 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 2 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tab SR 24HR 3 MG Anxiolytics - Long Acting NP PA Required G Alprazolam Tablet Disperse Anxiolytics - Benzodiazepines NP PA Required B ALPROLIX Antihemophilia Factor IX Agents P B ALREX Op. Antiinflammatory / Steroids Ophth. P B ALTABAX Topical - Antibiotic NP B ALTACE ACE Inhibitors NP B ALTOPREV Cholesterol - Hmg COA + Absorb Inhibitors: Low Potency Drugs/Combinations NP B Alunbrig Antineoplastics - Protein-Tyrosine Kinase Inhibitors NR PA Required B ALVESCO Antiasthmatic - Steroid Inhalants NP G Amantadine HCl Cap 100 MG Anti-Parkinsonian Drugs P G Amantadine HCl Syrup 50 MG/5ML Anti-Parkinsonian Drugs P G Amantadine HCl Tab 100 MG Anti-Parkinsonian Drugs NP B AMARYL Diabetic - Oral Sulfonylureas NP B AMBIEN Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B AMBIEN CR Sedative/Hypnotics - Non-Benzodiazepines NP PA Required B AMBISOME Antifungals - Assorted P PA Required > 90 days G Amcinonide Cream 0.1% Topical - Corticosteroids - High Potency N PA Required G Amcinonide LOTN Topical - Corticosteroids - High Potency N PA Required G Amcinonide OINT Topical - Corticosteroids - High Potency N PA Required B AMERGE Migraine - Selective Serotonin Agonists (5HT)--Tabs NP PA Required B Amicar Hemostatic P G Amikacin Sulfate Amino Glycosides P G Amiloride & Hydrochlorothiazide Diuretics P G Amiloride HCl Diuretics P G Amino Acid Electrolyte Infusion Electrolytes/ Nutritionals P G Amino Acid Infusion Electrolytes/ Nutritionals NP G Amino Acid Infusion SOLN 6% Electrolytes/ Nutritionals P G Aminocaproic Acid Hemostatic P G Aminophylline Antiasthmatic - Xanthines P B AMINOSYN Electrolytes/ Nutritionals P 12/17/2018 9:18:23 AM Page 5 Of 98 B Drug Name Drug Category P, N, Comment or R or G NR A B AMINOSYN II Electrolytes/ Nutritionals P B AMINOSYN-HBC Electrolytes/ Nutritionals NP B AMINOSYN-PF Electrolytes/ Nutritionals NP G Amiodarone HCl Tab 200 MG Antiarrhythmics P G Amiodarone HCl TABS 400MG Antiarrhythmics NP B AMITIZA GI, Constipation - IBS-OIC P PA Required G Amitriptyline HCl Antidepressants - Tri-Cyclics P G Amlodipine Besylate Calcium Channel Blockers--Amlodipines